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Can FG/Lab give us health utopia?
[ by Niall Hunter, Editor www.irishhealth.com]
Our health service is clearly broken, but can Fine Gael, in Government alone or with Labour, fix it?
Apart from how to deal with our economic catastrophe, how the next Government can make our health service more equitable, quality-driven, safe, and affordable is the other key issue in this general election campaign.
Both Fine Gael and Labour have produced detailed and impressive looking sets of proposals aimed at changing healthcare provision by adapting a universal health insurance (UHI) system, whereby everyone in the country would be insured and have equal access to quality GP and hospital care based solely on medical need and not size of wallet.
Labour gives speedier timeframes for introducing such changes, and slightly different ways to deliver the reforms compared to Fine Gael, but the proposals are similar in most respects.
Fine Gael's are based largely on the Dutch system of universal insurance, which it says provides a better health system at a lower per-capita cost.
These health plans look promising, incorporating as they do aspects of health systems in other developed countries that work reasonably well and seem to get more ‘bang' for taxpayers' bucks than we do in our current dysfunctional health system.
They are also ambitious, however, given that there is no extra State money to implement radical changes in how healthcare is delivered. So the plans must essentially be ‘budget neutral’.
The logistics of implementing such plans will be daunting.
The health consumer will justifiably fear that after getting bogged down with vested interests, resourcing issues and industrial relations hitches, we could have gradual health service changes over a 10-year period and end up with a system just as inequitable and inefficient as the one we must endure now.
In other words, pretty much a repeat of what has happened over the past decade.
The health reform process, for what it was, started by Michael Martin around 10 years ago and continued by Mary Harney has given us...er, the HSE. Also, other highlights such as co-located hospitals and the same old waiting list and trolley-ridden inequitable hospital system.
Not to mention, of course, a pay-as-you-go GP system which many who do not have the safety net of medical cards can no longer afford. What's the use in promising to move services from hospital to primary care if thousands currently avoid their GPs due to the cost of attending?
Many will welcome the fact that both Fine Gael and Labour plan free at the point-of-entry GP care, whatever the concerns about funding such a scheme.
Former Health Minister Micheal Martin, now leading Fianna Fail, has produced a party health policy which promises more of the same and which appears to be telling us (surely not?) that the HSE is actually a ‘good thing’.
However, what's done is done (or not done, mostly). We are at crossroads where we cannot afford not to reform our healthcare system.
Looking at Labour's policy, it is actually more detailed than the Fine Gael's FairCare plan and to date is the only one to give us fairly specific costings.
Fine Gael, somewhat cheekily, has sought to pick holes in Labour's costings for universal health insurance while producing very little the way of precise costings for its own insurance plan.
Labour's costings for universal hospital care provide for it to be funded from efficiency savings, but it admits that even with this there would be a funding shortfall of around €371 million by 2016, when its hospital scheme is due to be fully implemented.
It says it has projected that this shortfall will by then be covered by the fact that more people will be at work and therefore able to contribute to the insurance scheme.
The funding of its free GP scheme appears to be totally dependent on making savings elsewhere, in areas such as consultants' pay.
Fine Gael's Universal Health Insurance (UHI) plan is also to a certain extent dependent on more people being able to contribute insurance premia as the economy recovers. However, precise costings on how its UHI scheme would be funded are not given in any of its policy documents to date.
Health service savings Fine Gael has given details of to date are largely aimed at reducing the national deficit, rather than funding a new insurance scheme.
Presumably, an amalgam of the two parties' health plans plans will be produced should the two parties share Government.
Labour proposes that within around four years everyone will have free GP care at the point of entry, followed by universal hospital care.
The Fine Gael plan is more cautious about this and sets a longer timeframe of well over five years for free GP care to arrive, after the introduction of universal hospital care The FG plan provides for more people to be given doctor-visit medical cards in the meantime.
Overall, Labour's plan is in more of a hurry than its Fine Gael equivalent. Labour says its insurance system for GP and hospital care will largely be put in place during the life of one Government (4-6 years), whereas Fine Gael says its similar reforms will take much of the lifetime of two Governments - a period of up to 10 years - to bed in.
A pragmatic outlook would be that Fine Gael's timeframe is more realistic, given the extent of the changes planned and the state of the economy. Expect Labour to row back on its four to five year timeframe if it enters Government with FG.
Both plans have at their core the concept of universal health insurance (UHI) which will pay for everyone's GP, community and hospital care.
Under both plans, everyone in the country will be insured and everyone will get the same level of care. Access to care will solely be based on medical need, not bank account, and there will presumably be no long waiting lists.
Presumably the quality of care will be better too in a more efficient system.
Both plans have the attraction of removing uncertainty and inequity from the system. Both plans promise to cover completely or subsidise the health costs of those on low incomes, who would presumably get better access to hospital care.
Under both sets of proposals, those on middle and high incomes would compulsorily contribute through their earnings to varying extents to the universal health insurance scheme. This will cover them for hospital care and will mean they will no longer have to pay a fee for every visit to the GP.
Both parties have insisted that under their new schemes, nobody will pay any more than they may already be paying for healthcare through private health insurance premia and levies/taxes. We'll have to wait and see on that one.
FG and Labour have insisted that their new systems will remove uncertainty for the consumer in getting access to healthcare. Not just in terms of no longer having to go on a waiting lists, but also through not having to worry about continuing to afford the cost of maintaining their health cover.
Both proposals provide for the State to step in and cover the insurance of those who might suffer a major drop in income. Health insurers involved in running the new systems will be forced to offer standard core hospital, GP and community services to the whole population.
So, in theory anyway, we will have no more waiting lists, and no more invidious two-tier private-public care divide. The new system will cover people for care in both private and public hospitals regardless of their income or insurance status, as everyone will be insured for the same level of care.
Getting rid of the two-tier system should, again in theory, not matter to the hospitals and the doctors working in them, as they will get paid under the State-controlled insurance scheme, whoever they treat.
Both Labour and FG plans provide for hospitals to be paid according to their activity levels - essentially according to the number of patients they treat and the complexity of treatments they provide.
There would be no more ‘block grants’ given regardless of activity levels, and therefore no unexpected bed closures or trolley crises when the money runs out.
In Fine Gael's words 'the money follows the patient.' It says this will put the patient's , rather than the care provider's needs first , and will increase hospital productivity and improve accountabilty.
All in all, it sounds like Nirvana. So that's that sorted out then.
Back up le camion there for a minute. It all sounds too good to be true. Knowing how things often work out in this benighted isle, there is always the danger of the dream turning into a nightmare.
Micheal Martin can be accused of electioneering in raising the spectre of high individual payments to run the new system. However, neither Fine Gael nor Labour have to date been convincing in their reassurances that people will not end up paying substantially more.
We can't be sure whether the cost of funding the scheme will run out of control for both the State and the individual.
No health system is cheap to run and few systems elsewhere, however efficient they might try to be, can avoid the spectre of medical inflation, which is notoriously difficult to control, or the inevitability of ageing populations requiring a greater and more expensive quantity of care.
The person in the street would be justified in asking why, if private health insurance currently increases in leaps and bounds every year as it is, are things going to be different with universal health insurance?
Is UHI simply VHI in disguise? Both parties are adamant that they will control costs, but their mettle will certainly be tested on that issue.
Then we have another thorny issue. Who runs the system and how well will it be monitored?
Fine Gael proposes that under its UHI plan, everyone will have health insurance from one of a number of competing companies, providing equal access to a wide range of care. Tightly- regulated private health insurers would effectively run the system. There will be more autonomy for hospitals, which would be run by trusts.
Labour says it would have a combination of private and public insurers.
FG would split the HSE in two prior to the introduction of full UHI, into a healthcare commissioning authority and a care service authority, The HSE will be gone by 2016, and its staff mostly employed directly by the hospitals.
Under both parties’ proposals, the State and its agencies would have a more direct role in monitoring the health service, and there would be a new health safety authority.
In Labour's plan, a care purchase agency will be created from an amalgamation of the HSE and the National Treatment Purchase Fund, and this joint body would eventually become the public insurer.
Fine Gael has criticised Labour for seeking to retain the HSE, albeit in an altered form.
An amalgam of these scenarios may well work out, but many will fear that the new system will take on the worst aspects of HSE-style bureaucracy and free-market healthcare in the absence of strict accountability and Government control.
A nightmare scenario of a pre-Obama US style system benefiting the pockets of the insurers and providers and not the patents while skimping on quality may emerge in the absence of proper controls. Both parties say the new system will be strictly monitored.
However, parties promise a lot of things around election time.
Then you have another potential headache in changing the contracts of doctors and other staff to operate the new systems. Labour is promising to partly fund the new free GP system by cutting consultants' pay, a move that would have a good deal of popular support, but might be difficult to implement.
Fine Gael wants to renegotiate consultants' contracts (again) and cut their private fees. Not an easy task at the best of times.
Both parties are as yet unclear about exactly how much people who can afford to pay will actually pay under the new system, and particularly with Fine Gael's policy, some of the operational details are still a bit sketchy.
Then there’s the quality issue. With hospitals getting paid per patient or activity level, the State must ensure that quality is not sacrificed for quantity.
Finally, you might ask, quite apart from he grandiose plans, what do FG and Labour intend to do to solve the health service problems we have today - waiting lists, trolley waits etc?
Fine Gael is more vocal on this, promising a special delivery unit and threatening to sack managers who do not meet targets on trolley waits and waiting lists. However, we have had many unsuccessful initiatives before in these areas.
All in all, Fine Gael and Labour's health plans are ambitious and promise a health utopia, but as far as implementing the plans goes, the devil will be in the detail.
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